Medicare Will Probe Plans’ Networks Every Three Years

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By Mindy Yochelson

Medicare has been given the go-ahead to start reviewing managed care organizations every three years to determine if they’re offering enrollees enough doctors and other health-care providers.

The move comes after the White House Office of Management and Budget approved the Centers for Medicare & Medicaid Services’ request to switch from conducting reviews when a Medicare Advantage organization applies to be part of the program or when there’s a triggering event, such as a complaint or change in ownership.

The CMS said the triennial reviews would cost the managed care industry a little over $1 million annually for network adequacy documentation. But the agency said they’re needed to deflect beneficiary harm that occurs when networks are deficient.

A third of beneficiaries are in Medicare Advantage.

Minimum Providers, Maximum Travel

The CMS has network adequacy criteria that set out the minimum number of providers and maximum travel time and distance from enrollees to providers in each county.

But the Government Accountability Office in 2015 said the CMS’s processes for determining adequacy lacked certain elements and couldn’t ensure that MA networks continue to meet the needs of enrollees. The plans should be required to periodically submit their networks to the CMS for assessment against requirements, the report recommended.

The move comes at a time when the CMS is trying to limit reporting requirements for providers.

Some in the managed care industry told the OMB, which had to approve the information collection request, that they were unsure of the need for more frequent reviews. The Blue Cross Blue Shield Association, in a comment letter sent in 2017, questioned whether the $1 million cost for industry and a $626,000 bill for taxpayers are of value to all those affected. The CMS has regulations to assure adequacy, the association said. “The addition of a three-year network adequacy review imposes an undue burden on MAOs” to produce provider and facility tables for a given contract.

Other top companies in the MA industry include United Healthcare and Humana Inc.

A spokeswoman for America’s Health Insurance Plans told Bloomberg Law Jan. 4 the group is awaiting agency guidance before commenting.

Three-Year Approval

The OMB’s approval goes through the end of 2020. MA plan bids for 2019 have to be in to the CMS by June 4.

The CMS said in its request that if the OMB approves the three-year cycle, it would stop requiring reviews during the application process.

MA organizations will get letters from the CMS specifying which contracts are due for review and a “notation that CMS may take compliance actions if network deficiencies are found,” the CMS said.

‘Great Step’

The CMS’s move “is a great step toward improving the accuracy and adequacy of the networks,” Gretchen Jacobson, associate director of Kaiser Family Foundation’s Program on Medicare Policy, told Bloomberg Law Jan. 4.

Adequate networks are important for enrollees to get care in a timely manner and be able to see the specialist they want, she said.

“We’ve seen in our own work that some of the networks are very out of date,” said Jacobson, an author of an October 2017 foundation report on MA physician networks. “CMS has found many errors in the directories” so these reviews will hopefully improve that, she said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

For More Information

The OMB approval is at

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